Resident Autonomy in OR

[hightower]

I have a question about resident autonomy in the OR. Maybe this is a silly question but I really don't know how it all works. Do residents eventually perform surgery from start to finish without any supervision from attendings? If so, do the attendings check the work done before closure? Or does there always have to be a DPM in the OR? Or is the autonomy based on the confidence of the attending in the resident?

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[PADPM]

I have a question about resident autonomy in the OR. Maybe this is a silly question but I really don't know how it all works. Do residents eventually perform surgery from start to finish without any supervision from attendings? If so, do the attendings check the work done before closure? Or does there always have to be a DPM in the OR? Or is the autonomy based on the confidence of the attending in the resident?

Excellent question and a topic that has actually been discussed indirectly in the past.

There were some attendings on this board who have expressed that they allow residents to perform cases "skin to skin" (incision to closure) while the attending is not scrubbed or in some cases not in the room.

I personally have a very strong opinion about that and have NEVER not been in attendance AND scrubbed in on one of my cases. Yes, when I have confidence in one of the residents, I have allowed the resident to perform the procedure "skin to skin", but I'm right there at all times.

My office is a private practice and not a clinic. That's not to say that clinic patients deserve any less, but when patients go to a clinic they understand that they may be treated by students, residents, attendings, etc. When patients come to our offices, they are expecting to be seen and treated by one of the doctors associated with the practice and are in essence "paying" for one of us. They have hopefully been referred to our practice due to our reputation, not the reputation of our residents.

When that patient goes to the O.R., he/she is expecting me to be present. My patients understand a resident may be present and be involved with the surgery. This is not a lack of confidence in the residents, it is simply a responsibility to my patients. I will be in the O.R. the entire time whether I perform 100% of the case or whether I allow the resident to perform the case. I will also be available for my patient during the post operative period and will take care of him/her for all post operative visits, I will not have the resident perform these tasks.

Every surgical case is a time to interact and is a learning experience for the attending and the resident. Hopefully, everytime I'm performing a case with a resident I'm teaching something and learning something.

So, my answer to you is that as long as I'm the attending, the resident will never work unattended, though I may allow the resident to perform the entire case depending upon his/her skill level.

 

[hightower]

Excellent question and a topic that has actually been discussed indirectly in the past.

There were some attendings on this board who have expressed that they allow residents to perform cases "skin to skin" (incision to closure) while the attending is not scrubbed or in some cases not in the room.

I personally have a very strong opinion about that and have NEVER not been in attendance AND scrubbed in on one of my cases. Yes, when I have confidence in one of the residents, I have allowed the resident to perform the procedure "skin to skin", but I'm right there at all times.

My office is a private practice and not a clinic. That's not to say that clinic patients deserve any less, but when patients go to a clinic they understand that they may be treated by students, residents, attendings, etc. When patients come to our offices, they are expecting to be seen and treated by one of the doctors associated with the practice and are in essence "paying" for one of us. They have hopefully been referred to our practice due to our reputation, not the reputation of our residents.

When that patient goes to the O.R., he/she is expecting me to be present. My patients understand a resident may be present and be involved with the surgery. This is not a lack of confidence in the residents, it is simply a responsibility to my patients. I will be in the O.R. the entire time whether I perform 100% of the case or whether I allow the resident to perform the case. I will also be available for my patient during the post operative period and will take care of him/her for all post operative visits, I will not have the resident perform these tasks.

Every surgical case is a time to interact and is a learning experience for the attending and the resident. Hopefully, everytime I'm performing a case with a resident I'm teaching something and learning something.

So, my answer to you is that as long as I'm the attending, the resident will never work unattended, though I may allow the resident to perform the entire case depending upon his/her skill level.

Thanks for the response!

 

[densmore22]

A lot of other specialties allow their residents to perform without supervision, granted, they are not very complex cases. In my state, the R5 gen surg residents hold a full license to practice and there can operate on their own. This is more so they can run the resident clinic and not have an attending present. This scenario has been brought up at my residency, whether the R3 should be allowed to be fully licensed so they can function without an attending, but if it's an attending's pt, then they would still be present. Still waiting for the final verdict. I don't know how ortho does it, but I think their senior residents function without much supervision on straightforward cases (whatever that means). I must say, it's nice to have an attending present when you start to struggle or if there's an unexpected finding during a case.

 

[PADPM]

A lot of other specialties allow their residents to perform without supervision, granted, they are not very complex cases. In my state, the R5 gen surg residents hold a full license to practice and there can operate on their own. This is more so they can run the resident clinic and not have an attending present. This scenario has been brought up at my residency, whether the R3 should be allowed to be fully licensed so they can function without an attending, but if it's an attending's pt, then they would still be present. Still waiting for the final verdict. I don't know how ortho does it, but I think their senior residents function without much supervision on straightforward cases (whatever that means). I must say, it's nice to have an attending present when you start to struggle or if there's an unexpected finding during a case.

densmore,

Once again, my decision is independent of what is legal or allowed in the hospital. I have had numerous residents who are more than competent to perform surgical cases without me present. But that does not negate the fact that the patient entered my office, for my expertise, etc., and I would say it's safe to say the patient would expect me to at LEAST be present during the surgery!!

Yes, I do disclose to my patients that residents will be involved with their care, but I also guarantee the patient I will always be present, and I never have broken my guarantee. In my opinion it's simply a duty I have to my patient, regardless of the skill of the resident. It's still my patient and I'm still ultimately responsible.

It's my personal decision, but I also believe there may be legal ramifications if it ever came to trial and it was discovered that the surgeon of record (if you are billing for the case, YOU must be the surgeon of record), wasn't scrubbed for the case or in the room.

Which brings up another interesting point. Obviously, if any attending is bringing a patient to the hospital for surgery, he/she is also interested in getting reimbursed for the surgical procedure. It is ILLEGAL, yes ILLEGAL to bill for that surgery if any of these attending doctors did not scrub or where not in the room at the time of surgery. As stated above, in order to bill for a surgery, a doctor's name must appear on the op report as the surgeon of record. If the doctor did not scrub on the case or was not in the room, that is simply fraud. There is no sugar coating the situation. It is simply insurance fraud. Period.

Podfather is as seasoned as I am and I'm confident he will confirm my comments. If an attending doesn't want to scrub or stand in the room, then he/she better not bill that case or insurance fraud has been committed.

 

[347932]

I'm with PADPM 100%.

 

[that1guyfromFL]

densmore,

It's still my patient and I'm still ultimately responsible.

What is your position on cases that present to the ER?

Is there is ever a time you think residents need the training wheels taken off?

I have spoken to residents from many different programs and they all consider autonomy a very important facet of their training.

 

[PADPM]

What is your position on cases that present to the ER?

Is there is ever a time you think residents need the training wheels taken off?

I have spoken to residents from many different programs and they all consider autonomy a very important facet of their training.

I believe you may have missed my point. I did state that I often let the resident perform the case(s) skin to skin, which I believe is basically giving the resident autonomy. However, the resident is working for the institution, not for me. Therefore, when I am bringing "my" private patients to that institution, I still have an obligation to be present for "my" patient and not in essence abandon my patient to the autonomy of the resident. And as I've stated, if I did decide to leave the O.R. or not scrub, then I certainly can not bill for those services.

Once again, it is not a matter of confidence or lack of confidence or lack of trust. It's simply a matter of right/wrong. The patient is a private patient seeking my care, and therefore the patient will always be under my supervision, regardless of the skill of the resident.

A patient who enters the E.R. is a different story. The resident is acting basically in the capacity of a hospital employee and the patient is seeking the care of the hospital and/or a member of it's staff. The resident will act accordingly as per the hospital rules/regulations and as per the guidelines of his/her chairperson and residency director.

In these cases it is not unusual for a resident to act autonomously, until an attending is assigned to the case.

Yes, autonomy IS very important, but as an attending there are also obligations we have to our patients and that always comes first. Just because I'm standing there letting the resident perform the work, doesn't mean I haven't removed the training wheels. I'm very particular who I let touch my patients, and when a resident has earned that privilege, he/she can be sure their training wheels are off and they're "good to go".

 

[that1guyfromFL]

Thanks for the clarification PADPM.

 

[densmore22]

densmore,

Once again, my decision is independent of what is legal or allowed in the hospital. I have had numerous residents who are more than competent to perform surgical cases without me present. But that does not negate the fact that the patient entered my office, for my expertise, etc., and I would say it's safe to say the patient would expect me to at LEAST be present during the surgery!!

Yes, I do disclose to my patients that residents will be involved with their care, but I also guarantee the patient I will always be present, and I never have broken my guarantee. In my opinion it's simply a duty I have to my patient, regardless of the skill of the resident. It's still my patient and I'm still ultimately responsible.

It's my personal decision, but I also believe there may be legal ramifications if it ever came to trial and it was discovered that the surgeon of record (if you are billing for the case, YOU must be the surgeon of record), wasn't scrubbed for the case or in the room.

Which brings up another interesting point. Obviously, if any attending is bringing a patient to the hospital for surgery, he/she is also interested in getting reimbursed for the surgical procedure. It is ILLEGAL, yes ILLEGAL to bill for that surgery if any of these attending doctors did not scrub or where not in the room at the time of surgery. As stated above, in order to bill for a surgery, a doctor's name must appear on the op report as the surgeon of record. If the doctor did not scrub on the case or was not in the room, that is simply fraud. There is no sugar coating the situation. It is simply insurance fraud. Period.

Podfather is as seasoned as I am and I'm confident he will confirm my comments. If an attending doesn't want to scrub or stand in the room, then he/she better not bill that case or insurance fraud has been committed.

I wasn't disagreeing with you, so forgive me. I feel like you were taking my statement that I was disagreeing with you. I am in full agreeance. I think and am happy to have my attending's present for the case. I learn from them, they teach me things. I'm not ready to be on my own, I'm only an R1. I was just trying to point out that other specialties, ESPECIALLY at larger academic institutions, do have their residents operate without an attending present. To my knowledge, the pts are usually ones booked through their resident run clinic so having an attending of record is not as important (the R5 I'm assuming would be billed at the primary surgeon). Anyways, just wanted to clarify, I'm pro attending presence.

As far as the ED thing goes, you're not doing surgery on a pt in the ED, you're doing a procedure. The ED doc will bill it and "act" like the attending, even though they may not have been present. I will just go ahead and suture someone up or reduce a joint or whatever then converse with my attending, but would never do anything I wasn't certain was the correct thing without confirming it first. My attendings RARELY come into the ED to see a pt, only if the **** hits the fan. That's part of good training is allowing the resident to develop their critical analysis skills without compromising pt care.

 

[PADPM]

I wasn't disagreeing with you, so forgive me. I feel like you were taking my statement that I was disagreeing with you. I am in full agreeance. I think and am happy to have my attending's present for the case. I learn from them, they teach me things. I'm not ready to be on my own, I'm only an R1. I was just trying to point out that other specialties, ESPECIALLY at larger academic institutions, do have their residents operate without an attending present. To my knowledge, the pts are usually ones booked through their resident run clinic so having an attending of record is not as important (the R5 I'm assuming would be billed at the primary surgeon). Anyways, just wanted to clarify, I'm pro attending presence.

As far as the ED thing goes, you're not doing surgery on a pt in the ED, you're doing a procedure. The ED doc will bill it and "act" like the attending, even though they may not have been present. I will just go ahead and suture someone up or reduce a joint or whatever then converse with my attending, but would never do anything I wasn't certain was the correct thing without confirming it first. My attendings RARELY come into the ED to see a pt, only if the **** hits the fan. That's part of good training is allowing the resident to develop their critical analysis skills without compromising pt care.

No need to apologize, I didn't take anything you said as a disagreement and even if you did disagree you are entitled to your opinion!

Teaching institutions are a unique animal, especially if any of the attendings are employees of the hospital, which is often the case. If the attending is actually employed by the hospital, that makes the situation even MORE unique.

In essence, we are in agreement.